Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents as required by physician orders and facility policy. For one resident with a physician's order for continuous oxygen at 2 LPM via nasal cannula to maintain oxygen saturation above 90% due to COPD, the resident was observed without the nasal cannula in place. The nasal cannula was found inside a set-up bag, and the resident stated he had removed it earlier in the presence of staff. Staff did not ensure the oxygen was reapplied, and the resident's oxygen saturation was later found to be 75%. Despite subsequent interventions, the resident's oxygen saturation could not be stabilized, leading to a transfer to an acute care hospital. Interviews with staff revealed that the CNA who assisted the resident with personal care asked the resident to place the nasal cannula in the set-up bag and instructed him to use the call light for assistance in putting it back on. However, the CNA did not inform other staff or a licensed nurse about the removal of the oxygen, as he was called away to respond to another resident. The licensed nurse also did not notice whether the resident was receiving oxygen during morning rounds. For another resident, the facility failed to change the oxygen tubing, nebulizer, and mask according to facility protocols, which require weekly changes and clear dating of supplies. The resident's breathing treatment equipment was observed to be bagged and dated several months prior, despite an active physician's order for as-needed nebulizer treatments. The nurse confirmed that the equipment should have been changed weekly and verified the outdated supplies.